The Relationship Between Frailty and Postoperative Atrial Fibrillation in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis

Abstract

Background: Postoperative atrial fibrillation (POAF) occurs in roughly one-third of patients undergoing cardiac surgery, increasing mortality, morbidity, and healthcare costs. Frailty, a syndrome of physiological decline, is associated with poor outcomes after cardiac surgery. The link between frailty and POAF has not been clearly established. Methods: A systematic search of PubMed and EMBASE was conducted up to January 2025 for studies reporting preoperative frailty scores and POAF rates postcardiac surgery. Transcatheter aortic valve replacement (TAVR) studies were assessed separately. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) for frail vs. nonfrail patients were calculated using a random-effect model. Results: Eighteen studies involving 9098 patients (undergoing coronary artery bypass, surgical valve replacement, or both) were included. Meta-analysis indicated that frailty was associated with a higher risk of POAF (RR 1.20; 95% CI 1.08–1.33, p = 0.0008). Subgroup analyses showed consistent frailty effects across different patient ages, study designs, surgery types, and sample sizes. Notably, POAF risk was higher in studies using clinical frailty scales (RR 1.33; 95% CI 1.15–1.54, p < 0.0001) compared to those using surrogate imaging/lab-based methods (RR 1.10; 95% CI 0.92–1.33, p = 0.24) though comparison between subgroups did not reach statistical significance (p = 0.08). In 3 studies for patients undergoing TAVR, there was no association between frailty and POAF (RR 1.24; 95% CI 0.81–1.88, p = 0.32). Conclusion: This meta-analysis underscores the association between frailty and increased POAF risk in cardiac surgery patients, highlighting the need for comprehensive clinical frailty assessments in preoperative evaluations to identify high-risk patients and optimize perioperative management.